Impact of Functional Tricuspid Regurgitation on Survival: A Large Multicenter Cardiac Magnetic Resonance Study

Presenting Author(s)

• 

  Andrada C. Guta, MD, PhD

  Researcher
  Houston Methodist DeBakey Heart & Vascular Center
  Bucharest, Bucuresti, Romania

Primary Author(s)

• 

  Andrada C. Guta, MD, PhD

  Researcher
  Houston Methodist DeBakey Heart & Vascular Center
  Bucharest, Bucuresti, Romania

Co-Author(s)

• MX

  Mianli Xiao, PhD, MSc

  Biostatistician
  Houston Methodist DeBakey Heart & Vascular Center
  Houston, Texas, United States
• ML

  Meng Li

  Assistant Professor of Statistics
  Rice University, United States
• XT

  Xin Tan

  Student
  Rice University, United States
• SL

  Shizhen Liu, MD, PhD

  CV Imaging Research Specialist
  Piedmont Heart Institute
  Atlanta, Georgia, United States
• WS

  William Saunders, PhD

  Senior Data Scientist
  Atrium Health, North Carolina, United States
• EG

  Edward A. Graviss, PhD, MPH

  Scientist
  Houston Methodist DeBakey Heart & Vascular Center, Texas, United States
• 

  Maan Malahfji, MD

  Assistant Professor of Medicine
  Houston Methodist DeBakey Heart & Vascular Center
  Houston, Texas, United States
• 

  Carlos El-Tallawi, MD, FACC

  Physician/Cardiologist
  Houston Methodist DeBakey Heart and Vascular Center
  Houston, Texas, United States
• 

  Michael Elliott, MD

  Director, Cardiovascular MRI
  Sanger Heart and Vascular Institute
  Charlotte, North Carolina, United States
• 

  Venkateshwar Polsani, MD

  Director of Cardiovascular Imaging
  Piedmont Heart Institute
  Atlanta, Georgia, United States
• 

  Dipan J. Shah, MD

  Chief, Division of Cardiovascular Imaging Director, Cardiovascular MRI Laboratory
  Weill Cornell Medical College, Houston Methodist DeBakey Heart and Vascular Center, Houston, Texas, USA
  Houston, Texas, United States

Background: Functional tricuspid regurgitation (FTR) is common and has been linked to excess mortality. We aimed to determine whether quantitative measures of FTR severity independently predict mortality after adjusting for clinical and imaging covariates, including the Charlson comorbidity index, and to analyze proposed severity thresholds for identifying high-risk patients in a large multicenter cohort.

Methods: We included 5,091 patients who underwent comprehensive assessment by cardiac magnetic resonance (CMR), including quantification of FTR, at three medical centers across the United States (Houston Methodist DeBakey Heart and Vascular Center, Houston, TX; Piedmont Healthcare, Atlanta, GA; Atrium Health, Charlotte, NC) from 2008 through 2022. Patients were followed longitudinally for all-cause mortality. Kaplan Meier statistics were applied to assess how the expanded 5-grade tricuspid regurgitation (TR) classification (TR volume of < 30, 30-44, 45-59, 60-74, and ≥75 ml) was associated with all-cause mortality. Cox proportional hazards regression modeling was used to test for associations between FTR measurements (regurgitation volume and fraction) and outcomes, after adjusting for various covariates, including age, gender, race, Charlson comorbidity index, socio-economical status, right ventricular dilatation and dysfunction and tricuspid annulus diameter.

Results: Over a median follow-up of 3.6 years (IQR 1.4-5.0 years), 784 deaths occurred, corresponding to a mortality rate of 43 per 1000 person-years. Estimated survival at 1, 3, and 5 years was 93%, 85%, and 80%, respectively. Kaplan–Meier analysis demonstrated a stepwise decrease in survival across the expanded five-grade TR volume classification, with 5-year survival ranging from 83.6% (< 30 mL) to 50% (≥75 mL) (Figure 1). Quantitative FTR severity (by both regurgitant volume and fraction) remained independently associated with mortality after adjusting for potential covariates. Each 10 mL increase in regurgitant volume conferred a hazard ratio (HR) of 1.10 (95% CI 1.05–1.17), and each 10% increase in regurgitant fraction provided an increased HR of 1.22 (95% CI 1.14–1.30).

Conclusion: Quantitative FTR is a strong, independent predictor of mortality, even after accounting for comorbidity burden. Survival decreases progressively with increasing TR severity, both when expressed continuously and across the expanded 5-grade TR classification. These findings highlight that FTR should not be overshadowed by coexisting conditions but systematically assessed in routine cardiac imaging, with recognition of validated high-risk thresholds to guide monitoring and potential interventions.

Figure 1. Survival of functional tricuspid regurgitation patients according to the expanded tricuspid regurgitation grading system.